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Highlight + write note to state each finding to obtain the literature review from the guideline for all three articles.For the Literature Review Assignment  For the Literature Review Assignment  Please find the following:  Research problem and purpose  Literature review  Study framework  Research objectives, questions, or hypotheses  Study variables  Assumptions  Limitations  Research design  Population and sample  Methods of measurement  Data collection  Data analysis  Research outcomes   	 www.PRSGlobalOpen.com 1 INTRODUCTION There are reports of high psychological morbidity  among people opting for a cosmetic surgery.1–9 Up to 71%  of people with personality disorders, mainly borderline- type emotional instability disorder,2,10,11 seek aesthetic  surgical procedures with autolytic aims or unrealistic ex- pectations about the outcomes2,7; people with personal- ity disorders are described as demanding and irritable.12  Generalized anxiety disorder is one of the most frequent  disorders in the Mexican population, with a prevalence of  14.3%, mainly in women between 40 and 50 years of age,13  with higher anxiety in younger women before a surgical  procedure.14–17 The majority of patients are satisfied with  the results and report an improvement in the quality of  life after cosmetic surgery.2,18–21 A positive change in physical appearance has a posi- tive psychological effect that improves self-confidence and  self-esteem..2,17 Satisfaction with cosmetic surgery results  has also been related to age, since older patients have  more realistic expectations and are more satisfied with the  results than younger patients..21 Some studies have found  that self-esteem is not a determining component in the  motivation for cosmetic surgery.22 This study aims to describe personality traits, level of self- esteem, and anxiety in women undergoing cosmetic surgery  with body contouring, such as liposculpture or lipoabdomi- noplasty with or without placement of breast implants. PATIENTS	AND	METHODS Patients	and	Procedure Subjects were female patients who opted for cosmetic  and reconstructive surgery in a private practice in Mexico  City between May 2016 and May 2017 with the intention of  having a body-contouring cosmetic surgery. The investiga- Copyright © 2019 The Authors. Published by Wolters Kluwer Health,  Inc. on behalf of The American Society of Plastic Surgeons. This  is an open access article distributed under the Creative Commons  Attribution License 4.0 (CCBY), which permits unrestricted use,  distribution, and reproduction in any medium, provided the original  work is properly cited. From the *Department of Psychiatry, Clínica Emocia, Mexico  City; †Department of Plastic Surgery, Clínica Perfect Surgery;  Mexico City ‡Department of Physics and Mathematics, Instituto  Tecnológico y de Estudios Superiores de Monterrey, Mexico City  Campus; §Department of Dermatology, Clínica dermatológica  Soprano Skin, Mexico City; ¶Private practice; and ║Department of  Nutrition, Clínica Perfect Surgery, Mexico City. Background: There are reports on high psychological morbidity, mainly personali- ty disorders, among people opting for cosmetic surgery. This study aims to describe  the personality traits, level of self-esteem, and anxiety in women seeking cosmetic  surgery with body contouring, such as liposculpture or lipoabdominoplasty with or  without placement of breast implants. Methods: Subjects were 87 women between 18 and 60 years of age in Mexico City  who went to a private clinic with the intention of undergoing cosmetic surgery  with body contouring. A psychiatric interview was performed using three scales:  the Salamanca questionnaire for screening for personality disorders, the Hamilton  Anxiety Rating Scale, and the Rosenberg Self Esteem Scale. Results: The average age was 31 years, with 35% of participants having previously  undergone body-contouring surgery. Regarding personality, the patients did not  show a psychopathology level for diagnosing a personality disorder. Regarding  anxiety, 92% of the patients showed an average level of anxiety. High level of self- esteem was exhibited by 81 participants (93.15%), and six participants (6.9%) ex- hibited average self-esteem. Notably, no participant exhibited low self-esteem. Conclusions: The level of psychopathology of the patients was lower than expect- ed, the self-esteem was not affected prior to the surgical procedure, and the level of  anxiety did not cause dysfunction. (Plast Reconstr Surg Glob Open 2019;7:e2381; doi:  10.1097/GOX.0000000000002381; Published online 30 October 2019.) Estephania Del Aguila,   Psychiatrist* Jorge R. Martínez, MD† José L. Pablos, MS‡ Marino Huánuco, MD§ Victor M. Encina, MD¶ Ana L. Rhenals, MD║ Personality Traits, Anxiety, and Self-esteem in  Patients Seeking Cosmetic Surgery in Mexico City Disclosure:	The authors have no financial interest to  declare  in relation to the content of this article. DOI: 10.1097/GOX.0000000000002381 Received for publication December 12, 2018; accepted June 17,  2019. 10.1097/GOX.0000000000002381 Special Topic http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ https://doi.org/10.1097/GOX.0000000000002381 https://doi.org/10.1097/GOX.0000000000002381 https://doi.org/10.1097/GOX.0000000000002381 PRS Global Open • 2019 2 tion procedure was explained to them, and an informed  consent was also obtained. The inclusion criteria were be- ing a woman between 18 and 60 years of age, giving in- formed consent to participate in the study, and knowing  how to read and write. When they met these criteria and  consented to participate in the study, they were asked for  their sociodemographic data. A single psychiatric inter- view was performed, and three scales were applied. Scales Salamanca Questionnaire for Screening for Personality Disorder It is an interviewer-administered questionnaire with 22  items, two for each personality disorder, ie, 11 personal- ity traits/disorders that are subdivided into three groups:  group A (paranoid, schizoid, schizotypal), group B (anti- social, narcissistic, histrionic, emotional instability border- line subtype, emotional instability impulsive subtype), and  group C (anankastic, dependent, and anxious).23,24 These  subdivisions have been used in different classifications for  personality disorders, such as the International Statistical  Classification of Diseases and Related Health Problems  10th Revision, Diagnostic and Statistical Manual of Mental  Disorders (DSM IV), DSM IV-TR, and DSM 5, on which  this scale was based and which has thus grouped personal- ity traits and disorders based on their similarity.24,25 Each  disorder trait has a score range from zero to six24; in this  study, a disorder was considered present with a score of  six, and a marked trait was considered present with three  to five points, while a patient “without disorder” was con- sidered with zero to two points. The Salamanca questionnaire was developed at the  Faculty of Medicine of the University of Salamanca, as part  of a doctoral thesis, reporting an average total score of  1.35 and corroborating its clinical utility.24 Personality disorders are an enduring pattern of inner  experience and behavior that deviate significantly from  expectations of the individual’s culture, being inflexible  and dominant in a variety of personal and social situa- tions, causing deterioration in their functioning.23 The main characteristics corresponding to different  personality traits/disorders assessed by the scale are de- scribed hereunder.24–28 Hamilton Anxiety Rating Scale An interviewer administered a scale that aims at deter- mining the severity of symptoms of anxiety. It consisted  of 14 items, 13 qualifying the symptoms of psychological  anxiety (psychological malaise) and somatic anxiety (anx- iety-related physical symptoms), and one on the behavior  during the interview. Its internal consistency is 0.79–0.8,  and test-retest reliability is 0.96.29,30 Each item has a score  from zero to four (zero = no symptoms, and four = maxi- mum intensity), with a total score range from 0 to 56 re- sulting in an average, moderate to average, and moderate  to severe severity score.29,30 Rosenberg Self-esteem Scale It is a self-administered scale with 10 items. Cron- bach’s α reliability is equal to 0.754, between 0.46 and  0.67 (P

Jayageetha · Accepted Answer

www.PRSGlobalOpen.com 1
INTRODUCTION
There are reports of high psychological morbidity 
among people opting for a cosmetic surgery.1–9 Up to 71% 
of people with personality disorders, mainly borderline-
type emotional instability disorder,2,10,11 seek aesthetic 
surgical procedures with autolytic aims or unrealistic ex-
pectations about the outcomes2,7; people with personal-
ity disorders are described as demanding and irritable.12 
Generalized anxiety disorder is one of the most frequent 
disorders in the Mexican population, with a prevalence of 
14.3%, mainly in women between 40 and 50 years of age,13 
with higher anxiety in younger women before a surgical 
procedure.14–17 The majority of patients are satisfied with 
the results and report an improvement in the quality of 
life after cosmetic surgery.2,18–21
A positive change in physical appearance has a posi-
tive psychological effect that improves self-confidence and 
self-esteem..2,17 Satisfaction with cosmetic surgery results 
has also been related to age, since older patients have 
more realistic expectations and are more satisfied with the 
results than younger patients..21 Some studies have found 
that self-esteem is not a determining component in the 
motivation for cosmetic surgery.22
This study aims to describe personality traits, level of self-
esteem, and anxiety in women undergoing cosmetic surgery 
with body contouring, such as liposculpture or lipoabdomi-
noplasty with or without placement of breast implants.
PATIENTS	AND	METHODS
Patients	and	Procedure
Subjects were female patients who opted for cosmetic 
and reconstructive surgery in a private practice in Mexico 
City between May 2016 and May 2017 with the intention of 
having a body-contouring cosmetic surgery. The investiga-
Copyright © 2019 The Authors. Published by Wolters Kluwer Health, 
Inc. on behalf of The American Society of Plastic Surgeons. This 
is an open access article distributed under the Creative Commons 
Attribution License 4.0 (CCBY), which permits unrestricted use, 
distribution, and reproduction in any medium, provided the original 
work is properly cited.
From the *Department of Psychiatry, Clínica Emocia, Mexico 
City; †Department of Plastic Surgery, Clínica Perfect Surgery; 
Mexico City ‡Department of Physics and Mathematics, Instituto 
Tecnológico y de Estudios Superiores de Monterrey, Mexico City 
Campus; §Department of Dermatology, Clínica dermatológica 
Soprano Skin, Mexico City; ¶Private practice; and ║Department of 
Nutrition, Clínica Perfect Surgery, Mexico City.
Background: There are reports on high psychological morbidity, mainly personali-
ty disorders, among people opting for cosmetic surgery. This study aims to describe 
the personality traits, level of self-esteem, and anxiety in women seeking cosmetic 
surgery with body contouring, such as liposculpture or lipoabdominoplasty with or 
without placement of breast implants.
Methods: Subjects were 87 women between 18 and 60 years of age in Mexico City 
who went to a private clinic with the intention of undergoing cosmetic surgery 
with body contouring. A psychiatric interview was performed using three scales: 
the Salamanca questionnaire for screening for personality disorders, the Hamilton 
Anxiety Rating Scale, and the Rosenberg Self Esteem Scale.
Results: The average age was 31 years, with 35% of participants having previously 
undergone body-contouring surgery. Regarding personality, the patients did not 
show a psychopathology level for diagnosing a personality disorder. Regarding 
anxiety, 92% of the patients showed an average level of anxiety. High level of self-
esteem was exhibited by 81 participants (93.15%), and six participants (6.9%) ex-
hibited average self-esteem. Notably, no participant exhibited low self-esteem.
Conclusions: The level of psychopathology of the patients was lower than expect-
ed, the self-esteem was not affected prior to the surgical procedure, and the level of 
anxiety did not cause dysfunction. (Plast Reconstr Surg Glob Open 2019;7:e2381; doi: 
10.1097/GOX.0000000000002381; Published online 30 October 2019.)
Estephania Del Aguila,  
Psychiatrist*
Jorge R. Martínez, MD†
José L. Pablos, MS‡
Marino Huánuco, MD§
Victor M. Encina, MD¶
Ana L. Rhenals, MD║
Personality Traits, Anxiety, and Self-esteem in 
Patients Seeking Cosmetic Surgery in Mexico City
Disclosure:	The authors have no financial interest to  declare 
in relation to the content of this article.
DOI: 10.1097/GOX.0000000000002381
Received for publication December 12, 2018; accepted June 17, 
2019.
10.1097/GOX.0000000000002381
Special Topic
http://creativecommons.org/licenses/by/4.0/
http://creativecommons.org/licenses/by/4.0/
https://doi.org/10.1097/GOX.0000000000002381
https://doi.org/10.1097/GOX.0000000000002381
https://doi.org/10.1097/GOX.0000000000002381
Rajasureshwaran
Highlight
Rajasureshwaran
Sticky Note
Purpose/Aim
PRS Global Open • 2019
2
tion procedure was explained to them, and an informed 
consent was also obtained. The inclusion criteria were be-
ing a woman between 18 and 60 years of age, giving in-
formed consent to participate in the study, and knowing 
how to read and write. When they met these criteria and 
consented to participate in the study, they were asked for 
their sociodemographic data. A single psychiatric inter-
view was performed, and three scales were applied.
Scales
Salamanca Questionnaire for Screening for Personality Disorder
It is an interviewer-administered questionnaire with 22 
items, two for each personality disorder, ie, 11 personal-
ity traits/disorders that are subdivided into three groups: 
group A (paranoid, schizoid, schizotypal), group B (anti-
social, narcissistic, histrionic, emotional instability border-
line subtype, emotional instability impulsive subtype), and 
group C (anankastic, dependent, and anxious).23,24 These 
subdivisions have been used in different classifications for 
personality disorders, such as the International Statistical 
Classification of Diseases and Related Health Problems 
10th Revision, Diagnostic and Statistical Manual of Mental 
Disorders (DSM IV), DSM IV-TR, and DSM 5, on which 
this scale was based and which has thus grouped personal-
ity traits and disorders based on their similarity.24,25 Each 
disorder trait has a score range from zero to six24; in this 
study, a disorder was considered present with a score of 
six, and a marked trait was considered present with three 
to five points, while a patient “without disorder” was con-
sidered with zero to two points.
The Salamanca questionnaire was developed at the 
Faculty of Medicine of the University of Salamanca, as part 
of a doctoral thesis, reporting an average total score of 
1.35 and corroborating its clinical utility.24
Personality disorders are an enduring pattern of inner 
experience and behavior that deviate significantly from 
expectations of the individual’s culture, being inflexible 
and dominant in a variety of personal and social situa-
tions, causing deterioration in their functioning.23
The main characteristics corresponding to different 
personality traits/disorders assessed by the scale are de-
scribed hereunder.24–28
Hamilton Anxiety Rating Scale
An interviewer administered a scale that aims at deter-
mining the severity of symptoms of anxiety. It consisted 
of 14 items, 13 qualifying the symptoms of psychological 
anxiety (psychological malaise) and somatic anxiety (anx-
iety-related physical symptoms), and one on the behavior 
during the interview. Its internal consistency is 0.79–0.8, 
and test-retest reliability is 0.96.29,30 Each item has a score 
from zero to four (zero = no symptoms, and four = maxi-
mum intensity), with a total score range from 0 to 56 re-
sulting in an average, moderate to average, and moderate 
to severe severity score.29,30
Rosenberg Self-esteem Scale
It is a self-administered scale with 10 items. Cron-
bach’s α reliability is equal to 0.754, between 0.46 and 
0.67 (P  0.05). Only 32.5% of patients at 
some point turned to psychological care. Analysis of the 
relationship between history of psychological treatment 
and education showed that 54.2% of the patients with 
a bachelor’s degree had sought treatment, while only 
22.6% of those with the high school level did so (P = 
0.05).
Most of them did not present serious substance abuse. 
Out of all, 22.5% participants met the criteria for harmful 
tobacco use followed by alcohol use (alone or combined 
with tobacco and marijuana; 9.1%) and 2.5% for harmful 
use of cocaine and/or amphetamines.
Body contouring surgery has been previously done in 
35% of patients. In a search for an association between his-
tory of depression and previous cosmetic surgery, Fisher’s 
exact test turned out to be nonsignificant (P = 0.482).
Some psychotherapeutic and/or pharmacological 
treatment was suggested to 28.7% of participants at the 
end of the interview; the types of treatment were psycho-
Table 1.

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